8.03 Vaginitis
==============

agk's Library of Common Simple Emergencies

Presentation
------------

A woman complains of itching and irritation of 
the labia and vagina, perhaps with vaginal 
discharge or odor, vague low abdominal 
discomfort, or dysuria. (Suprapubic discomfort 
and urinary urgency and frequency suggest 
cystitis.) Abdominal examination is benign but 
examination of the introitus may reveal 
erythema of the vulva and edema of the labia 
(especially with Candida). Speculum examination 
may disclose a diffusely red, inflamed vaginal 
mucosa, with vaginal discharge either copious, 
thin, and foul-smelling (characteristic of 
Trichomonas or anaerobic overgrowth) or thick, 
white, and cheesy (characteristic of Candida 
and associated with more intense vulvar 
pruritis). Bimanual examination should show a 
non-tender cervix and uterus, without adnexal 
tenderness or masses or pain on cervical 
motion.

What to do:
-----------

- Take a brief sexual history. Ask if partners 
    are experiencing related symptoms.
- Perform speculum and bimanual pelvic exam. 
    Collect urine for possible culture and 
    pregnancy tests which may influence 
    treatment. Swab the cervix or urethra to 
    culture for N. gonorrheae and swab the 
    endocervix to test for Chlamydia. Touch pH 
    indicator paper to the vaginal mucus (a 
    pH>4.5 suggests anaerobic vaginosis, but 
    this is only useful if there is no blood or 
    semen to buffer vaginal secretions).
- Dab a drop of vaginal mucus on a slide, add a 
    drop of 0.9% saline and a cover slip, and 
    examine under 400x for swimming protozoa 
    (Trichomonas vaginalis), epithelial cells 
    covered by adherent bacilli ("clue cells" 
    of Gardnerella vaginalis and other 
    anaerobes), or pseudohyphae and spores 
    ("spaghetti and meatballs" appearance of 
    Candida albicans).
- If epithelial cells obscure the view of 
    yeast, add a drop of 10% KOH, smell whether 
    this liberates the odor of stale fish 
    (characteristic of Gardnerella, Trichomonas 
    and semen) and look again under the 
    microscope.
- Gram stain a second specimen. This is an even 
    more sensitive method for detecting Candida 
    and clue cells, as well as a means to 
    assess the general vaginal flora, which is 
    normally mixed, with occasional 
    predominance of gram-positive rods. Many 
    white cells and an overabundance of 
    pleomorphic gram-negative rods suggests 
    Gardnerella infection. Gram-negative 
    diplococci inside white cells suggests 
    gonorrhea.
- If Trichomonas vaginalis is the etiology, 
    discuss with the patient the options of 
    metronidazole (Flagyl) 500mg bid x 7d, or 
    2000mg once. The latter has practically as 
    good a cure rate, but obviously better 
    compliance, and shortens the time she must 
    abstain from alcohol for 24 hours after the 
    last dose because of metronidazole's 
    disulfiram-like activity. Sexual partners 
    should receive the same treatment. In the 
    first trimester of pregnancy, substitute 
    intravaginal clotrimazole 100mg vaginal 
    suppository qhs x7d, which is less 
    effective, but safer than metronidazole 
    vaginal gel. Metronidazole is 
    contraindicated in the first trimester and 
    controversial thereafter. Treatment of 
    asymptomatic patients can be be delayed 
    until after delivery.
- If Candida albicans is the etiology, 
    prescribe miconazole (Monistat) or 
    clotrimazole (Gyne-Lotrimin) 200mg vaginal 
    suppositories to be inserted qhs x 3d. 
    These treatments are available without 
    prescription. Prescription alternatives for 
    recurrences, which is active against fungi 
    other than Candida, are butoconazole 
    (Femstat) and terconazole (Terazol) one 5 
    gram applicator of cream qhs for three days 
    and seven days, respectively. Use of cream 
    also allows its soothing application on 
    irritated mucosa. A single oral dose of 
    fluconazole (Diflucan) 150mg po is at least 
    as effective as intravaginal treatment of 
    vulvovaginal candidiasis, and many patients 
    seem to prefer it. Gastrointestinal side 
    effects are fairly common and serious side 
    effects can occur. In pregnancy, halve the 
    dose and double the course of topical 
    clotrimazole, (the same as the regimen for 
    Trichomonas above).
- If the diagnosis is bacterial vaginosis, 
    which is an overgrowth of Gardnerella 
    vaginalis or other anaerobes, the strongest 
    treatment is metronidazole 500mg bid or 
    clindamycin 300mg bid x 7d. Metronidazole 
    vaginal gel 0.75% 5 grams bid x 7d is an 
    alternative which is more expensive but 
    carries fewer gastrointestinal side effects 
    than the oral form. Sex partners need not 
    be treated unless they have balinitis.
- To prevent rebound Candida vaginitis after 
    antibiotics decimate the normal vaginal 
    flora, or for treatment of mild vaginitis, 
    consider douching with 1% acetic acid 
    (half-strength vinegar) to maintain a 
    normal low pH ecology.
- Remember that any given patient may harbor 
    more than one infection.
- Arrange for followup and instruct the patient 
    in prevention of vaginitis.

What not to do:
---------------

- Do not prescribe sulfa creams for non- 
    specific vaginitis. The treatments above 
    are more effective.
- Do not miss underlying pelvic inflammatory 
    disease, pregnancy, or diabetes, all of 
    which can potentiate vaginitis.
- Do not miss candidiasis because the vaginal 
    secretions appear essentially normal in 
    consistency, color, volume and odor. 
    Non-pregnant patients may not develop 
    thrush patches, curds or caseous discharge.

Discussion
----------

Both Candida albicans and Gardnerella vaginalis 
(previously known as Hemophilus vaginalis or 
Corynebacterium vaginale), are part of the 
normal vaginal flora. A number of anaerobes 
share the blame in bacterial vaginosis. An 
alternate therapy uses active-culture yogurt 
douches to repopulate the vagina with lacto- 
bacilli. Candida vaginitis is more common in 
the summer, under tight or nonporous clothing 
(jeans, synthetic underwear, wet bathing 
suits), and in users of antibiotics and 
contraceptives (which alter vaginal mucus), as 
well as in diabetes mellitus, steroid-induced 
immuinosupression and use of broad-spectrum 
antibiotics. Trichomonas can be passed back and 
forth between sexual partners, a cycle that can 
be broken by treating both. Ask patients with 
vulvar pruritis, erythema and edema, but with 
otherwise normal saline, KOH and Gram stain 
microscopy, about the use of hygene sprays or 
douches, bubble baths or scented toilet tissue. 
Contact vulvovaginitis may result from an 
allergic or chemical reaction to any one of 
these or similar products and can be treated by 
removing the offending substance and prescrib- 
ing a short course of a topical or systemic 
corticosteroid.

References:
-----------

- Abbott J: Clinical and microscopic diagnosis 
    of vaginal yeast infection: a prospective 
    analysis. *Ann Emerg Med* 1995;25:587-591.
- Swedberg J, Steiner JF, Deiss F, et al: 
    Comparison of a single-dose vs one-week 
    course of metronidazole for symptomatic 
    bacterial vaginosis. *J Am Med Assoc* 
    1985;254:1046-1049.
- Martin DH, Mroczkowski TF, Dalu ZA et al: A 
    controlled trial of a single dose of 
    azithromycin for the treatment of 
    chlamydial urethritis and cervicitis. *N 
    Eng J Med* 1992;327:921-925.

Illustration
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img/cse0803.gif

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